A Review of the Influencing Factors and Treatment Methods of

Eating Disorders

Zhirou Yu

Beijing E-town Academy, Beijing, 100176, China

Keywords: Eating Disorders, Self-Esteem, Perfectionism, Cognitive Behavioral Therapy, Dialectical Behavioral Therapy.

Abstract: Focusing on the severe negative impacts produced by eating disorders, this paper reviewed 23 literatures for

summarizing recent findings on influencing factors and treatment methods of eating disorders. For influencing

factors, self-esteem, while manipulating body dissatisfaction, is negatively correlated with the development

of eating disorders. Perfectionism, or some of its components, has proved to have a direct relationship with

the development of eating disorders. For treatments, enhanced cognitive-behavioral therapy is broadly

recognized in its effectiveness and immense relief of eating disorder symptoms appeared in participants after

treatment, whereas dialectical behavioral therapy seems to solely reduce the amount of time and effort

consumed while treating. Additionally, dialectical behavioral therapy may address issues more related to

emotional regulation and act as an adjunct to family-based treatment. Future studies are expected to cancel

the dependence on correlations. Self-esteem and perfectionism are encouraged to be given more attention in

daily life.

1 INTRODUCTION

Eating disorders are severe psychiatric disorders that

should not be considered as a niche topic in today’ s

world. They are undoubtedly bringing serious

conditions, for example, the high rates of mortality in

anorexia nervosa patients, and proper coping methods

are in urgent need. However, claims like eating

disorders (ED) being unrecognized by clinicians and

unresponsive to current treatments still appear in

recent articles. This review summarized evidences in

more recent times for generating an update of the

related research findings.

This paper reviewed 2 major influencing factors

and 2 major treatment methods for ED, summarized

findings of previous scholars in recent years. A total

of 23 literatures from Google Scholar and Web of

Science are reviewed with their reliability carefully

considered. The aim is to determine the underlying

mechanisms of ED with respect to self-esteem and

perfectionism, discuss the effectiveness of enhanced

cognitive-behavioral therapy (CBT-E) and dialectical

behavioral therapy (DBT) for treating EDs, and give

suggestions for future researches. Peculiarly, self-

esteem and perfectionism are chosen because they are

factors easily detectable and estimable in daily life.

Discussion of these two topics is expected to elevate

the attention for maladaptive levels of self-esteem and

perfectionism in life.

2 INTRODUCTION TO KEY

CONCEPTS

2.1 Eating Disorders

Eating disorders (ED) are a group of complex

psychiatric conditions which induces severe

psychological and physical impairments. General

clinical features include abnormal eating behaviors

due to excessive attention to weight, food, and body

shape, but disorganized eating may also happen

despite the lack of those extra concerns. ED patients

are often subject to distressing social and physical

health pressures, and are no doubt susceptible to a

variety of mental diseases. Formidable mortality and

suicide rates result from ED, especially anorexia

nervosa. Basically, ED can be divided into two

categories: anorexia nervosa and bulimia nervosa.

Yu, Z.

A Review of the Inﬂuencing Factors and Treatment Methods of Eating Disorders.

DOI: 10.5220/0014389100004859

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Politics, Law, and Social Science (ICPLSS 2025), pages 523-527

ISBN: 978-989-758-785-6

523

2.2 Anorexia Nervosa

Anorexia nervosa (AN) presents as self-starvation.

Patients with AN devise multiple strategies, which

are basically harmful purging behaviors, to avoid

weight gain and finally attains critically underweight.

Other than receiving social pressures, psychiatric

conditions like depression and physical illnesses like

cardiac issues and infertility may also arise from AN.

2.3 Bulimia Nervosa

Patients with Bulimia nervosa (BN) suffer in a loop

of binge eating and purging or/and obsessive

exercise, sometimes also accompanied by fasting.

Contrary to those who experience AN, BN patients

have mostly normal body weight. Some patients can

also be overweight. BN, while causing extra social

burdens, introduces predisposition to psychiatric

conditions such as anxiety, depression, and substance

abuse disorders. Physically, nearly all body systems

can be significantly affected by BN.

2.4 Self-Esteem

Self-esteem refers to a person’s subjective believe of

self. Low levels of self-esteem indicate beliefs with

abasements and the ones holding positive opinions

toward themselves tends to end up with high levels of

self-esteem (Zanella & Lee, 2022). Scholars also

noted that self-esteem may imply an individual’s

well-being and health since it impacts their ability to

adapt and control risky behaviors (De Pasquale et al.,

2022). Problematically low levels of self-esteem are

found to be associated with multiple kinds of

psychiatric malfunctioning (Pelc et al., 2023)

including EDs.

2.5 Perfectionism

Perfectionism is interpreted as a preference for setting

exemplary and demanding standards for one’ s self

and being prone to produce harsh self-evaluations.

Individuals with this personality trait tend to pursue

an ideal version of self whose attainment is often

unrealistic. Although this trait is capable of

heartening people to improve, most scholars

underline its negative impacts more of the time.

Anorexia, for instance, is a mental illness commonly

known as being related to negative traits which may

result from, or are connected with, perfectionism.

3 FACTORS THAT INFLUENCE

EATING DISORDERS

3.1 Self-esteem

Low self-esteem has already been widely recognized

as a pervasive risk factor for the development of EDs.

Correlation between pathological eating and low self-

esteem has been found through meta-analysis, with

the effects notably more significant for females.

There is also a self-esteem theory derived by

researchers who are trying to explain the existence

and development of EDs (Zanella & Lee, 2022).

Many literatures viewed body dissatisfaction as an

important cognitive factor that links self-esteem with

abnormal eating behaviors. Pelc et al found a direct

relationship between satisfaction with appearance

and self-esteem and discovered that negative body

image induces low levels of self-esteem. In their

research, 233 students from Poland whose ages range

from 12 to 19 years old are surveyed. Female

participants accounted for 63% of the sample, while

males made up 37%. The self-esteem theory proposed

dissatisfaction directed at body shape elicited by low

self-esteem as the trigger of disorganized eating,

especially binge eating. In Zanella and Lee’s report,

low self-esteem is responsible for college students’

unpleasant feelings about their body image, but no

significant relationships are discovered between self-

esteem and disordered eating.

The Rosenberg Self-esteem Scale (RSES), a self-

report instrument invented by M. Rosenberg in 1965,

consists of 10 statements with a 4-point Likert scale.

This instrument evaluates the level of global and

personal self-esteem while the respondents imply

how well they believe themselves align with what the

10 statements described. Pelc et al utilized the Polish

version of RSES on adolescents in their study and

Pasquale et al employed the Italian version (De

Pasquale et al., 2022; Pelc et al., 2023).

A confirmed hypothesis in Pasquale et al’ s study

states that self-esteem mediates, but not directly

modifies, relationships between trait anxiety and

EDs. Meanwhile, a significant negative correlation

between binge eating and self-esteem is yielded from

their bivariate correlation study. 352 healthy

individuals aged between 18 and 37 years old

engaged in their study. 67.9% of the sample are

women, and 54% of the sample are students.

In Pelc et al’ s study, RSES indicated lower self-

esteem for people who had lost a remarkable portion

of weight in a recent period of time, which is one of

the strategies these kinds of people use while they

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want to establish higher degrees of self-esteem (Pelc

et al., 2023). They also noted that women tend to be

more affected, which, to an extent, coheres with what

Clomsee et al found. Likewise, Navarro et al’ s study

exhibited results suggesting that female adolescents

show higher degrees of body dissatisfaction

compared to male adolescents. Their sample included

355 students in primary schools with no mental or

physical diseases (Navarro et al., 2021). The size of

disparity on developing maladaptive diet intends

while being bothered by self-esteem between males

and females remains to be seen.

What is more, with their findings, Pasquale et al

took the relationship between having ED and owning

low self-esteem as a persistent vicious cycle, and this

cycle have also been proposed earlier by Zanella and

Lee. This could also be explained by a finding in

Pasquale et al’ s study: patients who know that they

are being treated because of having EDs had lower

self-esteem than patients who are not aware of the fact

that the treatments they are receiving are aiming at

EDs. Low self-esteem triggered the occurrence of

EDs, and being diagnosed with EDs again lowers

self-esteem.

To sum up, the impact of low levels of self-esteem

no doubt enhances the risk of developing EDs.

Therefore, in any case, eliminating the reliance of

correlations would be vital.

3.2 Perfectionism

Perfectionism, in high levels, had also been proved as

being able to induce a predisposition for EDs in

individuals. Importantly, several researchers

emphasized the necessity of seeing perfectionism as

a collection of many distinct dimensions. Martini et

al also explained it as a “two factor solution”, one

being adaptive and the other one maladaptive. The

maladaptive dimension, which is the specific

dimension that will be investigated here, associates

more with threatening factors including symptoms of

AN and BN (Martini et al., 2021). Additionally,

perfectionism is related to self-esteem.

Two literatures mentioned the use of

Multidimensional Perfectionism Scale (MES)

invented by Frost for assessing perfectionist behavior.

MES includes 35 inquiries while utilizing a 5-point

Likert scale. Martini et al assigned it to 139 AN

patients and 121 healty respondents as a control

group. Bernabéu and Marchena employed MES to

measure six dimensions in 312 adult respondents. The

two most vital dimensions are concern over mistakes

(CM) and doubts and actions (DA). CM is the one

most relevant to ED psychopathologies, expecially

AN, and DA is observed at a high level in people with

EDs. These two dimensions are shown as major

predictors of body mass index (BMI) and binge eating

behaviors and mediating factors between BMI and

emotion. Interestingly, different scoring in these two

dimensions form distinct behavioral patterns

regarding eating while cooperating with emotion:

high scores lead to rigid intake constrains, whereas

low scores tend to bring overfeeding (Bernabéu-

Brotóns & Marchena-Giráldez, 2022).

In individuals with AN, perfectionism has been

shown to be heightened compared to healthy people.

In a study associating perfectionism in AN with

personality, researchers conducted an evaluation on

personality traits that are highly correlated with

perfectionism in AN patient to assign them to either

low or high perfectionism group. The study had a

total of 193 participants. Self-reports and

questionnaires concerning factors including but not

limited to eating behaviors and perfectionism are

done. Results demonstrate that their high

perfectionism group exhibited more general

psychopathological symptoms in life, especially the

ones related to eating. The desire for thinness, and

also self-esteem, was found to be positively and

negatively correlated with perfectionism respectively

(Longo et al., 2024).

For BN patients, the vicious loop mentioned in 3.1

contributes to the enhancement of the level of

perfectionism: negative body images elevate the drive

for perfection and therefore prompts BN patients to

set hardly attainable fasting standards. Subsequently,

binge eating, unfortunately, is the most general

strategy for compensating the inability of complying

with the standards.

4 TREATMENTS FOR EATING

DISORDERS

4.1 Enhanced Cognitive Behavioral

Therapy

Enhanced cognitive behavioral therapy (CBT-E) is a

peculiar type of cognitive behavioral therapy (CBT)

developed specially for treating EDs. Its effectiveness

has long been proved by clinical trials. Although

normal CBT and CBT-E has been found to function

equally towards ED patients, research found that

CBT-E attains similar outcomes in a shorter period of

time. Moreover, in research with ED patients, self-

esteem elevated faster with less efforts from both

patients and therapists with CBT-E.

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According to Dalle and Calugi, the application of

CBT-E on adolescent ED patients can differ, mainly

on time duration, depending on patient situations. The

normative CBT-E for adults lasts for about 40 weeks.

After completing sets of interviews which assesses

the patients’ several conditions related with ED, two

models that explains EDs are introduced for the sake

of giving them a brief sense about what role do they

themselves play in this therapy. The psychological

model stresses the negative impact of the patients’

pathological self-evaluation scheme. With this

wanned appraisal system, dangerously low weight

and irrational ways of dieting are being thwarted to be

perceived as an issue, and senses of achievement after

successful fasting outweighed the harmful results.

Patients are encouraged to actively figure out a new,

healthier appraisal system during the therapy. The

disease model, which puts patients in a rather passive

role, interprets EDs as an entity parted from the

patients and prompts the patients to get rid of being

controlled by this presence under aid. The goal of

CBT-E in this case is to help the patients derive a

solution----an enhanced version for either their

appraisal system or the way they react to the control

of the ED entity. So far, as the researchers claimed,

62% of AN patient who completed a full CBT-E trial

had their symptoms relieved. 70% of the patients with

normal weight illustrated significantly diminished

disordered feeding behaviors after the therapy.

Another study proved a more intensive version of

CBT-E to be effective in treating both adolescents

and adults with AN. A total of 150 participants are

included. 74 of them are adolescents and the

remaining 81 people are adults. Upon the end of the

therapy, BMI increased among the AN patients, and

a mild decrease occurred at about 20 weeks after the

therapy ends. Psychopathological elements are said to

be reduced significantly at the end of the therapy and

only a trivial rebound was observed in follow-ups

(Dalle & Calugi, 2020).

4.2 Dialectical Behavioral Therapy

Dialectical behavioral therapy (DBT) is a treatment

model derived from CBT which concentrates

specifically on emotional regulation. Some

researchers address that DBT is an effective treatment

for the patients who still cannot achieve temperance

from binge eating after engaging in CBT treatments.

In a study comparing the effectiveness of DBT and

CBT on treating binge eating disorders (BED), BED

patients who received DBT were taught to healthily

regulate emotions in several ways and goals of

changing maladaptive eating behaviors were set. 74

respondents aged above 18 were involved in this

study. Contrary to what those researchers addressed,

this study concluded CBT to be more effective even

in populations that seems to be needing help

peculiarly on emotional regulation. Nevertheless,

while yielding analogical achievements compared to

CBT, DBT, at least the DBT used in this study was

less time-consuming (Lammers et al., 2020).

Moreover, DBT is proved to be able to deal with

harmful overcontrolling behaviors observed in EDs,

which is highly correlated with the development of

this disorder. Baudinet et al’ s research utilized

radically open DBT (RO-DBT), where 131

adolescents aged between 11 and 18 years old with

restrictive EDs participated sessions teaching

emotional regulation skills and completed measures

that assesses a wide variety of factors mostly related

to ED and overcontrol. Improvements in ED

symptoms, mood, and physical health appeared

(Baudinet et al., 2020).

DBT is also justified as a promising adjunct to

family-based treatment (FBT), a common treatment

for EDs. A study with 18 girls aged from 13 to 18

showed that ED patients, especially those with AN,

who experienced FBT accompanied by DBT,

displayed remarkably enhances in adaptive skills and

weight. Meanwhile, there is a decline in universal

dysfunctional coping strategies (Peterson et al.,

2020).

5 DISCUSSION

Conclusively, both self-esteem and perfectionism are

potential risk factors for the development of EDs.

Self-esteem acts more as a mediating factor by

manipulating the individual’ s satisfaction of their

own body, whereas perfectionism, since often being

divided into several aspects for measuring, exert

different levels of impacts when viewed from

different aspects. In addition, these two factors

negatively correlate with each other.

However, studies concerning these two factors and

EDs so far still had a reliance on correlation. Further

researches should attempt to uncover deeper

connections between them such as causal

relationships.

CBT-E, as a therapy expressly developed for EDs,

had already received testing and wide approval on its

effectiveness. It is already one of the most common

methods for treating EDs. Slight alternations on

applying this treatment in different studies have been

discovered, but all of the results recognized CBT-E’

s capability.

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On the other hand, there is not yet a specialized

version of DBT for treating EDs. This therapy does

not seem to be equally applicable or effective for all

ED patients with different etiologies. It is more

suitable to be utilized in scenarios where emotional

regulation plays a significant role. Studies indicated

that the major benefit, and perhaps the only reason, of

substituting CBT-E by DBT would be the relatively

effort-conserving quality of DBT. Furthermore, it

acts well as an adjunctive treatment for FBT instead

of working alone.

6 CONCLUSION

This literature review explored self-esteem and

perfectionism as influencing factors for EDs and

CBT-E and DBT as treatments for EDs based on 23

literatures. Low levels of self-esteem are found to be

a cause for high body dissatisfaction especially in

females, which increases the severity of, or risk of

developing EDs. High levels of perfectionism, or

some specific aspects that comprise perfectionism,

contributes to the development of EDs. CBT-E’ s

effectiveness for EDs has been proved by immense

relief of ED symptoms in patients while DBT seems

to require less time and effort from both patients and

therapists.

Further research about the influencing factors

should tempt to eliminate the dependence on

correlational relationships. As for the treatments,

further expansions and improvements regarding DBT

might be necessary for DBT to become a powerful

tool for treating EDs.

This article, reflecting on four specific topics

regarding ED, aims to sum up relatively novel

findings and opinions with reference to these fields

from recent years and indicate new notions for the

prevention and treatment of ED.

REFERENCES

Baudinet, J., Simic, M., Griffiths, H., Donnelly, C., Stewart,

C., & Goddard, E. 2020. Targeting mal-adaptive

overcontrol with radically open dialectical behaviour

therapy in a day programme for adolescents with

restrictive eating disorders: an uncontrolled case series.

Journal of Eating Disorders, 8: 1–13

Bernabéu-Brotóns, E., & Marchena-Giráldez, C. 2022.

Emotional eating and perfectionism as predictors of

symptoms of binge eating disorder: the role of

perfectionism as a mediator between emotional eating

and body mass index. Nutrients, 14(16): 3361

Dalle Grave, R., & Calugi, S. 2020. Cognitive behavior

therapy for adolescents with eating disorders. Guilford

Publications

De Pasquale, C., Morando, M., Platania, S., Sciacca, F.,

Hichy, Z., Di Nuovo, S., & Quattropani, M. C. 2022.

The roles of anxiety and self-esteem in the risk of eating

disorders and compulsive buying behavior.

International Journal of Environmental Research and

Public Health, 19(23): 16245

Lammers, M. W., Vroling, M. S., Crosby, R. D., & van

Strien, T. 2020. Dialectical behavior therapy adapted

for binge eating compared to cognitive behavior

therapy in obese adults with binge eating disorder: a

controlled study. Journal of Eating Disorders, 8: 1–11

Longo, P., Bevione, F., Amodeo, L., Martini, M., Panero,

M., & Abbate‐Daga, G. 2024. Perfectionism in

anorexia nervosa: associations with clinical picture and

personality traits. Clinical Psychology &

Psychotherapy, 31(1): e2931

Martini, M., Marzola, E., Brustolin, A., & Abbate‐Daga, G.

2021. Feeling imperfect and imperfectly feeling: a

network analysis on perfectionism, interoceptive

sensibility, and eating symptomatology in anorexia

nervosa. European Eating Disorders Review, 29(6):

893–909

Navarro-Patón, R., Mecías-Calvo, M., Pueyo Villa, S.,

Anaya, V., Martí-González, M., & Lago-Ballesteros, J.

2021. Perceptions of the body and body dissatisfaction

in primary education children according to gender and

age: a cross-sectional study. International Journal of

Environmental Research and Public Health, 18: 12460

Pelc, A., Winiarska, M., Polak-Szczybyło, E., Godula, J., &

Stępień, A. E. 2023. Low self-esteem and life

satisfaction as a significant risk factor for eating

disorders among adolescents. Nutrients, 15(7): 1603

Peterson, C. M., Van Diest, A. M. K., Mara, C. A., &

Matthews, A. 2020. Dialectical behavioral therapy

skills group as an adjunct to family-based therapy in

adolescents with restrictive eating disorders. Eating

Disorders, 28(1): 67–79

Zanella, E., & Lee, E. 2022. Integrative review on

psychological and social risk and prevention factors of

eating disorders including anorexia nervosa and

bulimia nervosa: seven major theories. Heliyon, 8(11)

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